SESSION K7. Personality Disorders in the Context of Human Development Bruce Gage, MD

Transcription

1 37th Annual Advanced Practice in Primary and Acute Care Conference: October 9-11, :55 SESSION K7 Personality Disorders in the Context of Human Development Bruce Gage, MD Session Description: S E S S I O N K7 Understanding the development of personality and its relationship to other aspects of development helps clarify the nature of personality development generally and personality disorders in particular. After exploring the context of personality development generally, the presentation will focus on the phenomenology of personality disorders that are most challenging in medical settings and offer some ideas and techniques for the clinician to use to improve interactions with this population. Learning Objectives: Following my presentation, participants will be able to: 1. Explain how stages of brain development are related to other developmental domains including cognition, morality, and personality. 2. Better distinguish personality disorders from major mental illness.

2 Disordered Personalities Bart Abplanalp, Ph.D. Bruce Gage, M.D. Agenda What are mental disorder and personality disorder? Development how we become who we are Biological Cognitive Moral Personality Personality disorder examples Phenomenology General principles of interaction Role playing Mental Disorder DSM-5 Clinically significant disturbance in Cognition Emotion regulation Biological or developmental processes underlying mental functioning Usually associated with significant distress or disability in social, occupational, or other important activities. DSM-5 does NOT consider the following to qualify as mental disorder: Expectable or culturally approved response to a common stressor or loss, such as the death of a loved one. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorder unless the deviance or conflict results from a dysfunction in the individual, as described above. General Personality Disorder DSM-5 A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events) 2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response.) 3. Interpersonal functioning 4. Impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. General Personality Disorder DSM-5 C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medications) or another medical condition (e.g., head trauma). Prevalence of Personality Disorder DSM-IV Θ All PD 10-15% Cluster A - odd Paranoid % Schizoid uncommon in clinical settings Schizotypal 3% Cluster B - dramatic ASPD 3% male, 1% female BPD 2% Narcissistic <1% Histrionic 2-3% Cluster C - anxious Obsessive-Compulsive 1% Avoidant 0.5-1% Dependent among the most frequently reported in MH clinics

3 Intrauterine Brain Development The Cortex and Neuronal Pruning Computation The brain develops from ectoderm, which also becomes skin. Damage to the brain at different times and/or by different means can lead to very different functional and behavioral problems. Neurons develop many new connections in the first years of life. During adolescence, neurons are lost and connections are pruned. Thereafter, few new neurons are created but connections are made and pruned throughout life, though not at as high a rate. Note: frontal areas, serving emotion and executive functions (such as decisionmaking), develop last. Myelin Formation Improving Communication within the Brain Genetics of Personality Modern studies are finding that around 50% of the variance in personality is genetic (most modern studies are between 1/3 and 2/3 and vary some with personality type) Twins reared apart and other typical genetic methods Temperament (e.g. sensation seeking, fearfulness) Extraversion/introversion, activity, self-control, purpose, agency, growth (psychic, learning), positive social relations Myelination is not complete until well into adulthood. Here again, the frontal lobes are myelinated last. Cognitive Development (Jean Piaget) Sensorimotor stage (0-2 years old) Learn through sensory observation Key development is object permanence Preoperational thought (2-7 years old) Thinking intuitive more than reasoned Egocentric Cannot think deductively Key development: use of language and symbols Cognitive Development (Jean Piaget) Concrete operations (7-11 years old) some stay here Able to use outside information (see from others perspective) Basic logical thought processes (grouping, what a rule is) Basic deduction Formal operations (11- young adult) Abstraction becomes possible manipulation of symbols, images, concepts Complex logic hypothesis testing, inductive logic Reasoning about situations they have not personally experienced Thinking about the future Searching systematically for solutions to problems.

4 Moral Development (Kohlberg & Gilligan) The Heinz dilemma A woman was near death from a unique kind of cancer. There is a drug that might save her. The drug costs $4,000 per dosage. The sick woman's husband, Heinz, went to everyone he knew to borrow the money and tried every legal means, but he could only get together about $2,000. He asked the doctor scientist who discovered the drug for a discount or let him pay later. But the doctor scientist refused. Should Heinz break into the laboratory to steal the drug for his wife? Why or why not? Stages of Moral Development Level 1 (Pre-Conventional) Obedience and punishment orientation avoid punishment, defer to authority Blind egoism it s good because I like it Self-interest orientation what's in it for me? Quid pro quo I ll scratch your back if you ll scratch mine Stages of Moral Development Level 2 (Conventional) Interpersonal accord and social conformity good boy/good girl Golden Rule behave well in hope of being treated well Authority and social-order maintaining orientation law and order morality Morality dictated by outside force Most adults are here Stages of Moral Development Level 3 (Post-Conventional or Principled) Social contract orientation - law as contract rather than rigid rule Valuation of compromise and inclusion Universal ethical principles principled conscience Laws only valid if just Acts done because they are right not for ends (ends do not justify means) Mutual respect as universal principle Rights and values are relative and contextual (but not egocentric) Personality Development Attachment (bonding) the reciprocal relationship between parents and infant Full attachment not complete until 3 months or beyond Those deprived of early attachment Show retardation in other aspects of development (e.g. cognitive) Are socially disabled throughout life, often diagnosed with personality disorders Personality Development Differentiation or autonomy the process of differentiation from the parents takes place in stages Parents need to be responsive but not too responsive Child may be overly dependent or independent in future relationships Patterns of behavior that we call personality result from experience (given the particular organism)

5 Impact of Abuse Repeated trauma (physical, sexual, severe neglect) has a variety of common effects mediated at least in part through changes in the amygdala and hippocampus Emotional instability Impaired cognitive development Sympathetic nervous system reactivity or arousal Fight or flight on high alert Self-destructive, self-defeating, and/or antisocial behavior Unstable interpersonal relationships, e.g. Have great difficulty accurately assessing the intentions of others Insatiable neediness (abused people and animals often develop overly dependent attachment on the abuser) Impact of Abuse Unstable self-image even to the point of not having a sense of identity A tendency to see others as all good or all bad may change rapidly Sexual promiscuity Substance abuse Medical problems especially those with substantial psychosomatic element Allergies, arthritis, asthma, bronchitis, hypertension, ulcers Poorer overall physical health and poor adherence to treatment Impact of Abuse Many people end up with diagnosis of Borderline Personality Disorder or other personality disorders Jails and prisons have many men and women with abuse histories 11 times more juvenile arrests 2.7 times more adult arrests 3.1 times more arrests for violence (adult & juvenile) About 1/3 go on to abuse their own children Cost to society close to $100 billion per year Most data from US Dept. of Health and Human Services Transference Refers to the patient transferring" feelings from key figures from earlier in their lives onto the professional. negative or positive feelings attraction or repulsion conflicts attitudes and expectations Arises from unresolved or unsatisfactory experiences with parents or other important figures Transference Make assumptions about the likes, dislikes, values, and attitudes of others (clinicians included) Usually activated by actions, appearance, and/or position of the other Almost always not consciously aware of it Example: Patient s father was an punitive, unreliable, and abusive Patient develops maladaptive assumptions about male authority figures Patient reacts to male staff in the same way he reacted to his father Transference The patient may make inferences about your reaction or thoughts I know what you are thinking and feeling Their responses may be irrational and disproportionate to the situation Countertransference transference is from doctor to patient It is more than just a patient reminding you of someone Don t be surprised if it happens to you, we all have issues Be aware that this is a very real aspect of our work Support and consultation are helpful

6 Obsessive Compulsive Disorder and Personality Shared feature is a quality of rigid adherence but they are very different Obsessive-Compulsive Disorder Ritual behavior (compulsions) and recurrent intrusive thoughts (obsessions) are paramount Consume a significant amount of time and energy Resisting them results in tremendous anxiety, ultimately necessitating that the person yield and engage in the action or indulge the thought Obsessive Compulsive Disorder and Personality Obsessive-compulsive personality Obsessions and compulsions may be a small part Primarily a preoccupation with orderliness, perfectionism and control Often self-righteous, nit-picking, can t see the forest for the trees Personality may be relatively normal OCD: Matchstick Men Narcissistic Personality Disorder Grandiose sense of self worth Pre-occupied with fantasies of power, unlimited success, brilliance, beauty, and/or ideal love Entitled Expects to be seen and treated as special, admired Narcissistic Personality Disorder Narcissistic Personality Disorder: Wall Street Lack of empathy Exploitative takes advantage of others for own ends Concerned with appearances and impression on others Hyper-sensitive to criticism, often responding with rage

7 Borderline Personality Disorder (BPD) Very difficult for medical and mental health If there is a lot of staff friction, consider BPD Very frequently associated with repeated childhood abuse Genetic temperament and other parenting factors important Borderline Personality Disorder (BPD) Pathological fear of abandonment Inappropriate, intense anger or difficulty controlling anger Emotional instability often inappropriately diagnosed bipolar Chronic loneliness, boredom, emptiness Unstable and volatile interpersonal relations Borderline Personality Disorder (BPD) Brief paranoid ideation and/or dissociative symptoms May become psychotic, but usually brief May have sense of themselves or circumstances not being real, not being inside their own body, or looking at world from afar (but not delusional) Recurrent self-harm and related behavior Borderline Personality Disorder (BPD) Brief paranoid ideation and/or dissociative symptoms May become psychotic, but usually brief May have sense of themselves or circumstances not being real, not being inside their own body, or looking at world from afar (but not delusional) Recurrent self-harm and related behavior (can be severe) BPD: Sid & Nancy PTSD Person experienced or witnessed event involving threat of death or harm to self or others & their response involved intense fear, helplessness or horror One or more of the following Flashbacks and/or intrusive memories of event Recurrent dreams of event Distress and/or physiologic reactivity when reminded of event

8 PTSD PTSD Person experienced or witnessed event involving threat of death or harm to self or others & their response involved intense fear, helplessness or horror One or more of the following Flashbacks and/or intrusive memories of event Recurrent dreams of event Distress and/or physiologic reactivity when reminded of event Avoidance of stimuli associated with the trauma and numbing of general responsiveness Increased arousal insomnia, irritable/angry, poor concentration, hypervigilance, startle Psychopathy Not the same as Antisocial Personality Disorder ASPD Psychopathy Psychopathy Malignant narcissism it s all about me Cheaters get the goodies as easily as possible Not intrinsically violent But generally not averse to hurting others or whatever is necessary to get what they want Biological component Genetic component Differences in brain electrical responses Punishment has limited ability to change behavior Biological foundation Psychopathy Checklist - Revised Psychopathy Checklist - Revised Aggressive Narcissism Glibness/superficial charm Grandiose sense of selfworth Pathological lying Cunning/manipulative Lack of remorse Shallow affect Callousness Failure to accept responsibility Socially Deviant Lifestyle Need for stimulation Parasitic lifestyle Poor behavioral control Lack of realistic long-term goals Impulsivity Irresponsibility Juvenile delinquency Early behavioral problems Revocation of conditional release Other items Sexual promiscuity Many short-term (marital) relationships Criminal versatility Acquired behavioral sociopathy

9 Psychopathy: A Clockwork Orange Dissent Among Droogs Droogs in the Water Droogs in the Pub Scene Interacting with PD in Clinical Settings Manage your reactions Know what bugs you Actively monitor your behavior, thoughts and emotions Learn to modulate your external behavior Facial expressions Posture Tone of voice Professional but dispassionate Red flags Rescue fantasy Guilt Not doing enough Feelings of inadequacy Destructive impulses Kick out Withhold treatment Treat with less desirable approaches Missing/dreading work Interacting with PD in Clinical Settings General principles Structure appointments Time for listening Opportunity to figure out what type of PD Each type has different need(s) Summary and brief corrections Exam Findings Options Regularly scheduled appointments Emergencies Deal only with the emergency everything else at regular appointment Matter of fact approach Nothing works Don t need to do anything if nothing to do What if it will simply be like this?